What Are the Differences Between Pre-Authorization & Pre-Certification?

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What Are the Differences Between Pre-Authorization & Pre-Certification?

In today’s world of healthcare, it is easy to get overwhelmed with the number of coverage options available and what goes along with each of them. This is especially true when addressing the differences between pre-authorization and pre-certification. These two practices were implemented in an attempt to decrease unnecessary spending. Getting the payer to agree that certain medical services are necessary before paying a claim enforces this.

What is Pre-Authorization?

Pre-authorization is the process that occurs when an insurance company refuses to cover a service unless the provider receives permission to offer you this service. This approval is required for a number of reasons, the main one being that the payers want to avoid unnecessary care and costs.

When utilizing pre-authorization procedures, your providers will go through each less expensive option before proceeding towards the more in-depth options. Once they have decided on the necessary form of care, physicians must wait for the proper approval before they can proceed. This can be timely but does reduce costs overall.

What is Pre-Certification?

Alternatively, pre-certification is a more specific requirement. This entails a payer needing to review whether the proposed service is medically necessary, or not. If the procedure is deemed necessary, a claim number must be provided as proof before a claim can be paid. This is usually the case for patients taking part in elective surgeries.

In this process, the physician associated with the payer must go over the physician’s order and determine the procedure “medically necessary.” They must also conduct an examination of any medical records to ensure the chosen procedure is “medically appropriate.”

The Approval Process for Each

In most circumstances, the patient will not need to be involved and the provider will reach out to the payer to acquire the approvals necessary to proceed. This is done after a practitioner completes a review of the clinical information attributed to the patient and submits it. Once approval is granted, a certification or authorization number is given, which usually contains a claim number as well.

Why Are Both Necessary?

Although some have differing opinions regarding these two practices, it is clear that they are both necessary for varying reasons. When it comes to pre-authorization, insurance companies are just trying to fulfill their duty of deflating out-of-control medical costs. It has been deemed necessary due to the countless circumstances involving care that really is inappropriate.

This process isn’t just helpful to insurers; it has proven to be helpful for patients and physicians as well. This is especially true regarding brand name and generic prescriptions. The implementation of this practice helps prevent costly brand name medications being prescribed when there is a generic equivalent available to the patient. Not to mention, when this review is done beforehand, it has been said to aid in the prevention of dangerous drug habits.
Pre-certification is also a necessary practice because it can offer a simpler route for those choosing to receive elective surgeries. Since they are non-emergency related treatments, there is no need to rush the process of the physician’s order review and the medical record examination. These are just a couple of the reasons why these practices have proven to be beneficial to all parties involved.

About Bedsiide

Bedsiide is a value-based health benefit that empowers you to navigate the complexities of the healthcare system.​

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